| Schore
(1994), whose research has highlighted the importance
of right-brain communications in psychotherapy,
notes that most research on psychotherapy focuses
on what the patient says during session, often utilizing
transcripts. Schore (1994) asserts:
Such
samples totally delete the essential "hidden"
prosodic cues and visuoaffective transactions
that are communicated between patient and therapist.
I suggest that the almost exclusive focus of research
on verbal and cognitive rather than nonverbal
and affective psychotherapeutic events has severely
restricted our deeper understanding of the dyadic
therapy process. In essence, studying only left
hemispheric activities can never elucidate the
mechanisms of the socioemotional disorders that
arise from limitations of right hemispheric affect
regulation. (p. 469)
In
this paper, I will present an approach to therapy
I use with adult patients who were molested as children
(AMACs) who suffer from post-traumatic stress disorder
(PTSD). This approach uses right-brain-to-right-brain
communications that serve an affect-regulating function
for the patient. Among the goals of this paper is
to describe how trauma early in life may cause biological
trauma to the brain, including the disruption of
verbal encoding of experience. An additional goal
of this paper is to describe a three-step technique
that may, based on the current understanding that
the brain retains some plastic capacities well into
adulthood (Shore, 1994), alter this process. This
technique will be illustrated with case vignettes.
It is my observation and belief that, most often,
AMACs suffering from PTDS seek therapy primarily
for an affect driven and state-regulated dyadic
experience (which I am referring to as an affective-state
relationship [ASR]) that addresses the affect and
state dysregulated symptomatology of PTSD. These
patients are seeking a relationship with an affectively
responsive and intuitively involved "other"
(the therapist) in which they will be able to explore
their extreme, yet adaptive, emotional and psychobiological
states, which emerged early in life in order to
survive their trauma and which altered their natural
drive responses. For effective treatment to occur,
the therapist needs to navigate through many territories
in which dysregulation occurs for both the therapist
and the patient.
The PTSD/AMAC's problems with attachment and self-regulation
stem from the type, severity, and timing of the
trauma. Sexual abuse at the hands of caregivers
early in life triggers conflicting emotions—arousal
and interest in the caregiver paired with fear,
terror, fight, flight, despair, humiliation—at a
time when brain development is occurring. Additionally,
natural temperamental systems of drive are altered.
Unlike a singular experience that may result in
PTSD, such as being at the effect of a bank robbery,
for the AMAC, more often than not, the sexual abuse
occurred frequently over a prolonged period and
severely impacted right-brain development, thereby
disrupting normal regulating and attachment-oriented
responses and, as Schore (1996) has noted, disrupting
the expression and processing of both emotional
information and nonverbal communication.
A feature of PTSD, which may appear to the therapist
initially as a symptom of problems with impulse
control, is what I call the "impulsive adaptive
function." This pervasive symptom of impulsivity
is, I believe, how the patient adjusted to his original
life supportive drives to survive the trauma. Although
these same impulses in adulthood cause problems
for the survivors, originally, I believe, their
construction was adaptive and helpful.
Lichtenberg (1989) and Jones (1995) describe motivational
systems that are relevant to working with traumatized
patients. Lichtenberg (1989) defines five motivational
systems: (a) physiological; (b) attachment; (c)
exploration/assertion; (d) withdrawal, or antagonism
in response to aversive events; and (e) sensual/sexual
pleasure. Jones (1995) proposes a motivational system
that he describes as the aggressive/competitive.
Identification by the therapist and the patient
of which motivational system a patient is using
at any particular point provides a window both to
the methods the patient used to survive his or her
trauma and to the original (before trauma) motivational
systems that lay dormant in the patient, ready for
reclamation once he or she comes to understand the
use of their current motivational systems as a reaction
to trauma. I have observed in treatment the reduction
of learned trauma-related responses and the emergence
of natural drive responses.
When impulsivity manifests in the treatment dyad,
particularly nonverbal impulsivity, it can appear
as a surge of inappropriate and spontaneous reactivity.
It can cause massive dysregulation for both the
therapist and the patient. Yet if the therapist
can ride this wave, he or she will have a peek into
the survivor's internalized history.
I believe that the "impulsive adaptive function"
is directly related to the dysregulation of the
trauma and not particularly related to the patient's
current environment and relationships. Survivors
react to triggers that remind them of the trauma
with both hyperarousal, as though they are in an
emergency, and at the same time numbing, punctuated
by hyperarousal, which result in an inability to
use affect states as signals to respond effectively
and efficiently. The response of survivors is to
go from stimulus to response without assessing what
is really going on (Krystal, 1978). These psychobiological
trauma-based affects, states, motivational systems,
and impulses are stored within the patient's nonverbal
right-brain emotional systems and are communicated
to the therapist nonverbally. The therapist needs
to utilize this information as though it were a
"word." This adaptive response, as I have
observed its development throughout the course of
treatment, initially appears as impulsive, by which
I mean disruptive to the treatment due to how dysregulating
its appearance or presence becomes to both the therapist
and the client. Yet when the response is welcomed
by the therapist, understood, and metabolized by
surrendering to it through state, affective, and
somatic experiences, eventually the adaptive response
of the client is seen as a method whereby the patient
adapted and altered his or her natural drive responses,
which are unconscious, presymbolic, procedural,
and somatic. These responses involve both affect
and state to survive trauma and in adulthood traumatic
triggers or signals. And their appearances in treatment
need to be welcomed.
An example of how understanding impulsivity can
be effective in psychotherapy is the case of Uma.
She had been sexually abused by her father from
infancy until age 10. The reoccurring ritual was
for Uma's mother to get Uma interested in and excited
about family outings or other exciting treats as
a precursor to the abuse. Uma learned to dissociate
and deny any and all feeling about her abuse. As
an adult, she engaged in severe sadomasochistic
relationships. After a period of abstaining from
engaging in sadomasochism, she began to do very
well in treatment. Her mood was more stabilized,
she was less depressed, and she felt happy for the
first time in her life. About 4 months later, all
of a sudden, she became severely suicidal, enraged,
and contemptuous of me. She humiliated me, shamed
me, and blamed her suicidal feelings on me. She
attributed them to my failure in treating her and
said her demise would be my fault, a therapist's
living nightmare. My dread increased. I did what
was needed ethically and legally, but most importantly,
I felt such a deep sense of helplessness and shock,
as well as incompetence and shame. This event appeared
so "impulsive," there were no apparent
triggers. Only months later did I learn that Uma
needed me to understand the state of helplessness
she experienced before she herself could move from
relationships based on aggression and sadomasochism
to relationships based on attachment. Her capacity
to physiologically respond to closeness with dissociation
mixed with inflicting and receiving sexual pain
was transformed into responses to closeness colored
with responses of attachment. She became attached
to me after effectively communicating to me her
own underlying sense of helplessness, dread, despair,
and massive confusion.
The therapeutic approach that I am proposing for
the treatment of the PTSD/AMAC is in three steps.
In Step 1, the therapist needs to be receptive to
the patient's dysregulated states and affective
experiences, thus visiting the patient's traumatically
adjusted adaptive responses. In Step 2, the therapist
needs to mobilize and regulate the dysregulated
state by experiencing the dysregulation and then
exiting those feelings and bodily experiences by
responding with increased or decreased arousal and/or
increased or decreased calming (i.e., soothing,
restoration, conservation). Finally, in Step 3,
the therapist needs to deliver back to the patient
the regulated state through an interactive dyadic
state and affectively regulated right-brain-to-right-brain
communication. When I use the words "receive,"
"became a tenant or a resident of," "visit,"
"became a guest," "acquiesce,"
I am referring to Step 1, describing the fraction
of a second wherein the patient communicates an
internal experience to the therapist through soma
and affect, using nonverbal right-brain communications
(e.g., vocal rhythm tones and sounds; a variety
of gazes and looks: gaze averts, still gazes, hypergazes,
constricted pupils, dilated pupils; gustatory responses:
stomach making noises, feeling like vomiting; muscleloskeletal
responses: arching 90 degrees, 180-degree turns,
posturing, jumping, running, hopping, feelings,
or affects). If this experience is received by the
therapist through a unilateral bridge of receptivity
from patient to therapist through the medium of
soma and affect, the right brain, the therapist
will experience some of the patient's unconscious,
fertile, and critical information including early
adaptive impulsive responses and information about
the patient's unedited, unfiltered internal experience.
Therefore the therapist must receive it first and
then begin to sort it out during and after experiencing
it, while involving a bilateral affective-state
exchange. This method of therapy embodies a template
for the repair of the patient's primitive parts,
which during this phase of treatment are unresponsive
to symbolic or reflective thought. As Michael Robbins's
(1993) paradigm so eloquently suggests, therapists
cannot necessarily assume that their patients possess
an internalized representation of cognitive-affective
experiences or representations of self from representations
of others. Furthermore, one cannot assume that the
patient has the capacity for appropriate, adaptive
self-regulatory functioning, let alone the ability
to move from primary process to reflective or interpretive
experiences. This requires that the therapist is
attuned not so much to the overt behavior of the
client as to the internal states of the client,
as Schore (1996) points out.
With
the advent of neurobiological studies, we are
now able to support with neurobiological evidence
a method of treatment that makes possible positive
outcomes for primarily nonverbally equipped patients
who have trauma stored in the right brain.
According
to Schore (1994,1997a), in early development, the
caregiver functions as a psychobiological regulator
of the behavior and physiology of the developing
brain of the infant. The maturation of homeostatic
regulatory systems in the right frontolimbic cortex
is dependent on the quality of the psychobiological
attachment. If there is unregulated interactive
stress and prolonged episodes of heightened levels
of negative affect (fear, humiliation, shame, despair,
anger, rage, intense excitement, and arousal)—which
is the core of trauma and sexual abuse—this will
result in a growth-inhibiting environment that disrupts
the experience-dependent development of the prefrontal
system.
The reason this information is critical in adult
treatment, particularly with AMAC PTSDs, is that
there is anatomical evidence that the prefrontal
limbic cortex retains some of the plastic capacities
of early development. Specifically, changes in the
right orbitofrontal cortex and its subcortical connections
have been detected in patients as a result of successful
psychological treatment (Schore, 1997b). This finding
provides support for the efficacy of psychotherapy,
in particular therapy that focuses on the affect-state-regulated
relationship of patient and therapist (which Schore,
1997b, describes as "reciprocal mutual influence")
that mobilizes fundamental modes of development
and continuance of previously interrupted developmental
processes. Schore (1997b) asserts:
Experience-dependent
plastic changes in the nervous system remain throughout
the lifespan. In fact, there is now very specific
evidence that the prefrontal limbic cortex . .
. retains the plastic capacities of early development.
The orbital frontal areas of the limbic system,
even in adulthood, continue to express anatomical
and biochemical features observed in early development,
and this properly allows for structural changes
that result from psychotherapeutic treatment.
(p. 16)
Nonverbal
interactions take place at preconscious-unconscious
levels and are represented in the right-hemisphere-to-right-hemisphere
communications that are involved in the expression
and processing of emotional information and in nonverbal
communications (Schore, 1996). This processing reads
traffic of visual signals and prosodic auditory
signals that effect emotions. This psychobiological
communication system is a mechanism thought to be
responsible for mediation of attachment. These informational
systems occur as fast-acting, automatic, regulated
and unregulated emotional states in relation to
the patient and therapist. This right-hemispheric
activity is dominant for the interactive transfer
of affect and state.
To further illustrate this process as well as integrate
the three-step process, I will describe the case
of Jane. Jane entered treatment with acute PTSD.
Not long after our work began, Jane started describing
some explicit memories of her mother using toys
to penetrate her while changing her undergarments
when she was 3 years old. At one point, while I
was listening to Jane, I found it impossible to
move my arms (Step 1). I felt immobilized, paralyzed,
and numbed. Then I began to notice my feeling state.
I felt overwhelming helplessness. The patient began
discussing horrifying images, and I wanted to run
out of the room. I sat with these sensations. Jane
kept talking. I noticed Jane was in a mildly dissociative
state and appeared to feel very little about what
she was describing. I (Step 2) stayed with the feelings
I was experiencing. I did not talk, but instead
I moved, groaned, grunted, sighed, squirmed, and
experienced my feelings and my bodily changes. I
did not interpret. Then, toward the end of the session,
I began to implement self-regulating, self-soothing,
containing behaviors, which served a grounding function.
For example, I told her we would now get ready for
her to go back into the world and would therefore
discuss everyday events, like what time it was,
what her daily plans were, and what she will wear
that evening. At that point, I realized I still
could not move. I was unable to get up, my forearms
were paralyzed. I mentioned this, in a very soothing
voice, "Oh my, Oh my goodness, my arms won't
move. Hmmm, curious." The prosody of my voice
indicated that all was well, as though a breeze
had just moved over my face. I (Step 2) then calmed
myself further (something Jane could not do during
her trauma), began moving my fingers, slowly regaining
enough movement to stand. All through this I was
self-regulating. I said good night and so did Jane.
This turned out to be a significant moment in the
treatment, which later resulted in Jane's being
able to affectively experience what in the session
just described she had communicated to me through
nonverbal process.
Jane was well aware of her ability to withdraw in
response to trauma. She had no skills to self-regulate,
or access to other adaptive responses (i.e., assertion,
aggression, attachment). Soon after the session
in which I became immobilized, Jane said that she
had had a similar experience in her youth; she described
an incident of her mother binding her arms when
her father had oral sex with her. As a young girl,
she had learned to paralyze her arms, and more generally,
she learned how to play dead and deaden parts of
her body. She referred to this adaptive self-regulatory,
primary process, state-adjusting event as her "body
game." I never responded to Jane's description
of her "body game" with words. But at
some point, it became apparent that Jane was aware
that her state had a profound impact on me. Jane
then felt safe enough to experience the helplessness
and terror that she had stored in her adaptive unconscious
state. After that point, I never experienced such
immobility with Jane again. It had been mobilized
and—in a dyadic-state-regulated manner experienced
by me, the listener of her internal world—dysregulated,
reregulated and dyadically communicated. The nonverbal,
affective-state communication was not received as
misattunement and polarization, but as an opportunity
to better understand Jane's internal state and affective
world. I was attuned within a millisecond of Jane's
internal world of helplessness and immobilization.
Jane did not have the capacity to move from dissociation
or negative states for prolonged periods of time.
Oftentimes after sessions that included flashbacks
or episodes of amplified negative states, she would
remain for days in a somewhat dysregulated state.
Sometimes autoregulation was only achieved by complete
isolation and withdrawal. This gravely affected
her ability to have relationships and or to work.
But after this dyadic experience I had with her,
whereby I attempted to autoregulate with her there
in the room, Jane began to display behaviors that
indicated that she had an increased ability to enter
dysregulated states, receive regulatory responses
from me, and then internalize and, after time, autoregulate
within a shorter period of time. Her impulsive response
to survive primarily by withdrawal began to shift
to a more assertive/aggressive capacity with an
increased ability to experience attachment.
As described earlier, Jane labeled her response
to trauma her "body game." Interestingly,
after the session in which I became immobilized,
Jane's experience of the "body game" changed.
Paralysis and freezing gave way to screaming, sweating,
and a desire to fight the perpetrator. The latter
was concretized as a metaphorical protector: the
"body game buster," who took the form
of a burly monster who would kill off the parents
during the trauma. While she was experiencing the
identification with the aggressor, this gave her
access to a survival mechanism that she had not
formerly experienced. It, most importantly, mobilized
an amplification of the aroused state and deamplified
for Jane her former response of playing dead (conservation
and restoration as means of survival). At this point,
her sessions were filled with laugher. Needless
to say, her deep depression began to lift. Jane
never acted out on the identification with the aggressor,
but she did utilize this part of her newfound physiological
capacity and brain chemistry to work creatively
as a graphic artist. Additionally, she now had the
ability to respond competitively and had the capacity
to feel a modicum of attachment.
Jane was in therapy with me for six years, and upon
leaving therapy had a profoundly positive life.
The "body game" was transformed into horrific
computer graphic images, which Jane created for
a major film studio. She became involved in an intimate
relationship. She continues to send me letters and
photos, and computer images, of course.
The following case illustrates the ASR technique
when treating PTSD/AMACs. The clinical phenomena
presented below are nonverbal, right-brain communications
that, while impulsive and affectively and physiologically
extreme, are not responsive to reflection, left-brain
word-driven communications, but need to be metabolized
through the affective right-brain-to-right-brain
dyad.
Jason's father was a seemingly good father, upstanding
citizen, and businessman. But at night when Jason
was 5-12 years old, his father would penetrate him
anally. Jason's father would remind Jason that this
was because he loved him and he had to teach him
to "pay his debt," because he was a child,
the only way he could pay his dad was by doing "his
responsibility." Jason talked about this from
the onset of treatment in a dissociated and numb
state with flat affect.
Jason's "impulsive adaptive functions"
manifested in enactments of withdrawal from his
attachment to me surrounding payment of fees and
keeping appointments. Regarding the former, he would
have excuses for not paying at the end of sessions,
such as forgetting his checkbook and wallet. Around
the issue of keeping appointments, he would cancel
less than 48 hours before appointments, even at
times calling at the last minute, or he would forget
his weekly scheduled time.
As treatment progressed, I (Step 1) began to be
receptive to Jason's dysregulated states and affective
experiences, and I thought that with time I would
understand them as Jason's traumatically adjusted
adaptive response to feelings of rage, anger, contempt,
and helplessness, paired with states of numbness,
exhaustion, flight responses, fight responses, and
many others. Interestingly, all of these acquiescences
to dysregulated states occurred during procedural
exchanges regarding Jason's payments and appointments.
I (Step 2) mobilized these states and affects in
session without discussion. For example, when I
told him he needed to pay as agreed, I was terrified,
palms sweating. He did pay. Afterwards, I doubted
my abilities as a therapist; I had fantasies of
terminating the treatment or perhaps not charging
him at all, in order to avoid feeling this thalamic
dread (Bion, 1990), but I continued to mobilize
these complex responses. And then, while addressing
payment and scheduling, I made efforts to regulate
my state. This required delivering (Step 3) mobilizing
assertion, soothing my own withdrawal responses,
and continued attachment to Jason instead of being
frozen in the terror. The verbal content was not
about my extreme reactions.
When acquiescing to Jason's states and affects,
I understood that I was experiencing a sample of
his experience. Therefore, I cherished and held
the interactions in highest regard.
After about 6 months, Jason began to have an assortment
of his own state and feeling reactions to payments
and scheduling. Of note, this shift coincided with
the mobilization of his state and affect when talking
about his father's penetration of him. He manifested
less withdrawal and hyperarousal and more interest,
assertion, excitement, and aggression. His tone
became loud; his eyes began darting back and forth;
he stared at me with intense confrontation and anger.
Concurrently, Jason learned to regulate his mobilized
states as well as his feelings, and he developed
an ability to self-sooth. Jason had stored these
feelings that were triggered in regard to attachment
with caring paired with torture. Had I not held
to our original scheduling and financial agreements,
I would have been unconsciously defending and colluding
with Jason. Although this content area provoked
acute terror in me, after this phase of treatment,
its value was clear to me. It was apparent that
Jason eventually trusted that his paying me did
not mean one of us would be the victim and the other
the perpetrator, but it enabled him caring and some
healing instead. Therefore, there was an unpairing
of terror and the therapy-related procedures of
paying and scheduling. Finally, responsibility acquired
a different meaning to Jason, freeing him from unconsciously
and impulsively reacting to responsibilities from
the perspective of his trauma.
The point here is: I (Step 1) momentarily became
a tenant in Jason's depressed state and dissociation.
I then (Step 2) moved and mobilized to a state of
assertion, interest, and excitement, where I was
able (Step 3) to regulate enough to take care of
myself and my practice, enforcing fees and scheduling.
This regulated state was apparent through the content
of fee and scheduling. He then paid without conflict
and showed up without problem. But I needed to reside
in his state and affect in order to effectively
receive the nonverbal content Jason was sending
me.
In closing, I think that heightened dyadic state
and affective levels need to take place in treatment
to accomplish repair. It is my belief that if this
is an element of the therapy, the treatment may
serve as a reparative relationship in which the
patient can further heal his or her trauma. The
therapist needs to experience the patient's symptomatology
from a secondary position because the original trauma
happened to the patient not the therapist. From
this perspective, the therapist can facilitate the
growth of self-regulation for the patient through
the therapist's alterations in physiological responses
acquired by engaging in what Shore (1997b) describes
as "reciprocal mutual influence," or what
Bion (1962) refers to as "reverie," or
what Marcus (1998) discusses as the analyst maintaining
a state of reverie so the analyst's unconscious
will be able to hear the patient's unconscious.
This is possible because the therapist has a feeling
for how it was for the client and can offer state
and affective alternatives to reactions that the
patient had to his or her trauma. Repair is done
through the therapist's ability to self-regulate
and then feed that self-regulation back to the patient
through preverbal right-brain-to-right-brain experience.
Finally, if the therapist can resist initially using
words as a primary intervention, when affectively
dysregulated and reregulated exchanges are occurring
during the right-brain-to-right-brain communication,
the therapist will have a greater understanding
of how the trauma was internalized by the patient.
For effective treatment, the therapist cannot deny
the existence of these presymbolic experiences,
only to have the client need to escalate with increased
impulsivity, chronic acute dysregulation, and negative
attachment styles in treatment, which are efforts
by the patient to drive information into the therapist
because the original sending of information was
not received. The patient is concurrently hoping
the experience will be repaired and the rupture
will be noticed. The therapist needs to notice,
experience, and, as an attuned caregiver, feed back
only what is palatable to the patient through affect
and state during periods of treatment where nonverbal
communication is critical. I have utilized this
process of treatment, implementing the affective
exchange, and I have experienced it as a positive
treatment modality with positive results. The usage
of words has been secondary during these points
of heightened affective-state communications.
References
Bion,
W. R. (1962). Learning from experience. London:
Heinemann.
Bion, W. R. (1990). W. R. Bion Brazilian lectures.
1973. Sao Paulo,
1974. Rio de Janeiro/Sao Paulo. New York, Brunner/Mazel.
First published 1990 London, Karnac Books.
Jones, J. M. (1995). Affects as process: An inquiry
into the centrality of affect in psychological
life. Hillsdale, NJ: The Analytic Press.
Krystal, H. (1978). Trauma and affects. Psychoanalytic
Study of the Child, 33, 81-116.
Lichtenberg, J. (1989). Psychoanalysis and motivation.
Hillsdale, NJ: The Analytic Press.
Robbins, M. (1993). The mental organization of
primitive personalities and its treatment implications.
Journal of The American Psychoanalytic Association,
44, 755-785.
Schore, A. N. (1994). Affect regulation and the
origin of the self: The neurobiology of emotional
development. Hillsdale, NJ: Erlbaum.
Schore, A. N. (1996). The experience-dependent
maturation of a regulatory system in the orbital
prefrontal cortex and the origin of developmental
psychopathology. Development and Psychopathology,
8, 59-87.
Schore, A. N. (1997a). Early organization of the
nonlinear right brain and development of a predisposition
to psychiatric disorders. Development and Psychopathology,
9, 595-631.
Schore, A. N. (1997b, March). Psychobiological
affect regulation: An essential mechanism of both
development and psychoanalytic treatment. Paper
presented at American Psychological Association
17th Annual Division 39 Meeting, Denver, Colorado.
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